This interview discusses what TMS can be used for, what protocols to be used and any supplements that may be given to the patient
Tell us about yourself Mr Shryer. How did you come to start Blackhawk TMS?
Blackhawk TMS began in 2013 a few years after I had seen the first Neurostar, which was really the leader of the field, the first machine approved by the FDA. I thought it was smoke and mirrors at first. I thought it was junk science and snake oil. I thought that for quite some time until I started hearing more and more stories about people getting well. People had been on medications for years and had not responded. I think the term ‘treatment-resistant depression’ is really a misnomer. It’s treatment non-responsive because treatment-resistant depression sounds like you’re suggesting that the patient is resistant to treatment. No, they weren’t resistant to treatment, they just weren’t able to respond to the treatment provided.
TMS gave them the opportunity to respond to treatment because it accessed a part of the brain that had never been touched before. That is a very interesting phenomenon and a very interesting way to perceive how treatment should be done – to turn on the neurons that have not been firing, to alleviate depression, to decrease anxiety and to promote wellness in a very integrative method.
How do you describe TMS to new patients coming in and having it for the first time?
When someone calls in and says, “what is transcranial magnetic stimulation?”, first thing I tell them is that it is not shock therapy, it is not inducing electricity into your brain in any way, shape or form. It doesn’t require sedation and it doesn’t require hospitalization. You can come to the treatment, be taken care of, have your treatment and leave, go back to school or work, whatever you would like to do.
How it works in the brain is by turning on neurons that have been dormant and it does that by an electromagnetic pulse, about the same amount as an MRI machine – 1.5 to 2 Tesla. It penetrates the skin, the skull, and all that magnetic pulse does is turn on neurons and get them to fire. It really is a concept of rebooting the brain or priming the pump, getting those things to turn on again. That’s what antidepressants try to do but fail so often because people have polymorphisms that prohibit them from responding to a drug. They’re simply not capable of responding to a drug adequately.
But what TMS does, is it doesn’t require a systemic approach, there are no side effects, so I tell them there are no side effects. There are really no downsides. “The worst side effect you could have”, the FDA will want to say, “is seizures” and that scares people. The likelihood of having a seizure with TMS is about the same as having a seizure after taking a Prozac. It’s about the same statistical possibility, quite remote, about 1 in maybe 2 million. So it’s very very low in the sense of, if someone does have a seizure, they probably have a co-occurring or undiagnosed problem.
What kind of indications do you treat for here and Blackhawk TMS and what indications have you seen the most success with?
TMS is only indicated by the Food and Drug Administration. The FDA approves it only for depression but those patients have failed one antidepressant at or above the usual normal dosage and that’s what the FDA says. The drug companies tend to disagree with them. They say it must have failed four antidepressants, two augmentations and some bona fide type of therapy, psychoanalytic therapy, relationship therapy, psychodynamic therapy, something that has to be documented. Patients can then be authorized by the insurance companies to be able to receive TMS
What indications do people typically think TMS might be good for but it in fact isn’t?
Currently, in the United States, people are interested in treating many different things for TMS. Depression, of course, is the only authorized one. Anything else besides depression is off-label, so if you’re just treating anxiety, that’s unfortunately off-label. It’s very effective but you should not treat someone for it if they have a bona fide seizure disorder. We said that initially but now people are actually using TMS to treat patients with seizure disorder using low 1 Hertz inhibitory to decrease the seizure threshold. If you use a high-frequency excitatory pulse, certainly you can bring on a seizure but you can decrease the seizure threshold by doing 1 Hertz inhibitory.
What kind of pain is TMS good at treating?
That’s a real good question because TMS is not being seen as being a harbinger of new developments in the whole treatment of pain. Migraine, complex regional pain syndrome, trigeminal neurology – which is just a burning sensation coming down into the facial muscles from the trigeminal nerve, often bought out by failed surgery for sinus problems. Migraine is actually one of the only other FDA approved treatments for TMS but it’s done with a very small handheld machine called eNeura. That is a transcranial direct current that fits right on the forehead. That seems to show some efficacy, some help to treat migraine. All of the Neuropathies, diabetic neuropathies, trigeminal problems, neuropathic pain of any kind, complex regional pain syndrome, those are the things that we found out that work so far.
So would you say it’s any sort of neuropathic pain that’s originating in the brain, but other types of pain that may be originating from trauma and other parts of the body, not so much?
Not so much because that’s a pain that actually is due to an injury. The referred pain from the neuropathies is actually due to an injury that did occur but then what happens is the brain misinterprets the electrical impulses of that healing area and continues to decode those impulses as being painful, and so by tamping down the hyper excitatory components of cortical excitation, the pain is diminished.
You had mentioned that you use L-methylfolate in your patient population when you’re treating with TMS. Can you explain why you use L-methylfolate?
There’s a company called Jaymac that produce something called EnLyte and EnLyte-D. What all the good research has shown is that 75% of patients with treatment resistant depression have the inability to metabolize folate properly just from folic acid, down to L-methylfolate. And when the body stops producing things like neurotransmitters, such as dopamine, norepinephrine and serotonin, that stuff harbingers depression. So by augmenting the production, instead of trying to keep what little neurotransmitters are around – which is the antidepressant concept – is to keep the ones you have in the synapse. What this does is, it looks at why you don’t have enough neurotransmitters to start with and so L-methylfolate helps you produce those and often helps avoid the necessity for antidepressants at all.
How do you know if somebody needs L-methylfolate supplement?
A very simple buccal swab test called MTHFR polymorphism test. It’s available now by mostly every testing lab around, LabCorp, Quest Diagnostics. Now, the drug companies probably knew that the antidepressant manufactured for years was a component of this and you think that somebody would have produced an L-methylfolate derivative long long ago. I wrote a paper called ‘Brain Prep TMS’ in conjunction with Jaymac Pharmaceuticals showing how it just makes good sense and I tell anybody who does TMS that if you want to increase your odds of success, put the person on L-methylfolate because here you have the production of the neurotransmitters and then you have the mechanism, the TMS machine to get the neurons firing and now they’re going to learn how to fire and produce and release neurotransmitters on a much more robust level. It’s just absolutely a harmonious way of approaching the treatment of depression.
What other kinds of supplements do you give or recommend for your patients?
Besides EnLyte-D and EnLyte, or if they’re a woman they can also get EnBrace Hr – which is EnLyte also – some good over the counter supplements that you can buy; N-acetylcysteine is very good, GABA is a good supplement for anxiety but all of these supplements work harmoniously in conjunction with TMS, which is really important, because a lot of these people come in with, I call it a sort of raggedy brain. They’ve spent years on antidepressants that have impacted their ability to methylate properly or the neurotransmitters have been out of whack, so we have to restore the brain to health. With the addition of TMS, we are rebooting the brain, we’re getting the brain to work the way it was designed to work.
Tell us a little bit more about the new research around anhedonia with the inability to feel pleasure and how TMS is helping people with this. It’s more of a rare condition.
It is somewhat probably underrepresented actually. There’s probably more people with depression that have a component of anhedonia than people realize because you can use an antidepressant and talk therapy from now until the cows come home, but if the person has a type of neurobiological anhedonia, they’re simply not going to experience pleasure. Their symptoms of depression will alleviate some but the anhedonia, that inability to feel pleasure, imagine not being able to have that joyful feeling you experience as a child, on Christmas morning, or if you’re a musician, to play and feel that good feeling from performing a good musical piece, that’s what anhedonia is all about. It’s the inability to feel pleasure in anything. It is a vacuum, it’s like flatline and so research out of ‘Toronto Western’ has shown that a different location to treat anhedonia, which is the dorsal orbitofrontal cortex, right over on the right side of the right eye with inhibitory pulses goes a long way. It decreases anxiety, alleviates suppression and alleviates anhedonia. It’s fairly amazing.
What kind of protocol do you use for that?
AF8, which is a way to find the Beam method for determining F3. That was the method for determining the location for EEG electrodes and so we have F3, F4, dorsomedial and AF8 (points to location on his head), which is the location just above the right eye to stimulate with inhibitory pulses, to be able to access the anterior cingulate.
Do you use a theta burst continuous protocol?
You can use a theta burst continuous, which is much shorter because the 1 Hertz inhibitory takes much longer, probably 1,200 seconds per treatment.